This research explored the manifestation of PAL in the clinical learning environment of undergraduate medical students with regard to developing clinical-reasoning skills. Students deploy various categories of PAL to advance their clinical-reasoning skills, although they were largely unaware of these processes, and facilitation of PAL is not consistently provided. Based on our results, we identified three topics of discussion regarding PAL and learning clinical reasoning, which are elaborated below.
The first topic concerns the environment. The learning context in which students need to develop their clinical-reasoning skills is often not conducive to self-directedness and collaborative learning with their peers[32]. We observed that groups of students placed at a clerkship location are often allocated to different workplaces within the same location to ensure they do not hinder each other in their work. Concurrently, the context of modern-day clinical practice is adapted to future patient care, which also leads to changes in the student learning environment. The availability of the student working room, where students would typically meet each other, is often reduced, resulting in students mingling with residents and medical specialists. While this change can positively impact students' visibility within the community of practice[33, 34] and highlight their roles as apprentices to clinical supervisors, it has led to the removal of a dedicated meeting space. Such a space is crucial for enabling PAL discussions where students can freely exchange ideas without fear of judgment from their assessors[12].
The second topic involves the role of peers in the clinical-reasoning learning process. In this research, we observed a reduced trust of some students in their peers’ (developing) expertise. The same-level peers they use for co-regulated learning during their Bachelor’s, are typically replaced with clinical supervisors during their Master’s program, as is also shown in other research[19, 35]. This could be attributed to the fact that students are a part of a community of learners[36, 37] during their Bachelor’s program, and that when they enter clinical practice they feel the need to take part in that specific community of practice with the medical specialist at the center[33, 34]. Slowly, their community of learners disintegrates and merges into this community of practice, leaving the role of peers in a state of uncertainty. During their Masters’ program students develop new ways to use peers for their clinical-reasoning learning process. Whereas during their Bachelor’s program, students’ peer-to-peer contact moments were more formal and explicit (i.e. group assignments, team-based learning), they become more implicit and informal during their clinical clerkships (i.e. sparring partners). This research contributes to making these implicit PAL activities explicit, providing insights into the dynamics and opportunities to support students’ clinical-reasoning learning process in practice.
The third topic reflects an internal struggle for students. On the one hand, this generation of students applies a more individualistic approach towards learning in the workplace than those before them, not to be confused with a dislike for teamwork[20, 38]. Although they acknowledge and value the role of their peers in their own clinical-reasoning learning processes, they prefer individual interactions with patients over those that occur together with a peer. This matches the anthropological view that people in the West are more individualistic than those in other parts of the world[39, 40]. Some respondents mentioned experiencing a sense of competition, which they believed could discourage their involvement in PAL. Since this individualism seems to be embedded into the students’ generation, more effort is needed for a change of behavior – a change that we deem necessary for a future of healthcare workers who are self-directed learners and excellent collaborators[41], behavior that contributes to patient-centered care and arguably better clinical-reasoning skills[42]. PAL could be of help in this behavior change.
Overall, these three topics describe important variables of students for either the success or failure of using PAL at the workplace for their clinical-reasoning development. Furthermore, they provide ample inspiration for practical implications and future research. Bringing a more collective awareness to the students’ individualistic behavior means changing the work-learning environment. PAL can be used to achieve these objectives, but in practice, is often presented as a formal learning activity. This adds to the prevailing tendency to structure students' learning formally around the daily activities of the community of practice, rather than organizing those activities in a way that fosters lifelong learning for all community members, including students[43].
Strengths and limitations
This research was conducted in The Netherlands, a country that is part of the Western world. Although more countries around the world are part of the same culture, it must be noted that these results possibly do not represent other areas of the world. This institute was conducted at one academic institute and its affiliated hospitals. This may be considered a limitation, although in one affiliated hospital students from another institute were included. Lastly, there are certain forms of bias associated with this type of research that should be considered, like observer bias, attentional bias, and reporting bias.
One strength of this study concerns the methodology wherein all the data of the interviews and clinical observations were consistently collected and coded by two researchers. This initiated rich and deep discussions within the research group during analysis. Another notable strength of this study was the inclusion of two undergraduate students (SH, EV) as members of the research group. This helped in the validation of the interview guide and triangulation of the data.